RN Clinical Documentation Specialist – Sign-On Bonus

University Of New Mexico - Hospitals; Belen (NM); Sur place; USD 70 000 - 100 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus

Relocation Assistance

Résumé du poste

UNMH Jobs in New Mexico seeks an experienced Registered Nurse with Clinical Documentation Improvement expertise to support the HIM Clinical Documentation department. You will review medical records to ensure accurate diagnoses and DRG assignments, communicating findings to physicians to improve documentation quality.

The role emphasizes concurrent review during hospitalization, collaboration with physicians and care teams, and ongoing education to enhance documentation standards.

Qualifications

• RN licensure in New Mexico required.
• Minimum 1 year of clinical documentation improvement experience.
• Bachelor's degree preferred.
• Certification in coding or documentation improvement preferred.

Responsabilités

• Review principal and secondary diagnoses with physicians to assign working MS-DRG.
• Conduct concurrent reviews and tracking of admissions for documentation quality.
• Interpret clinical data, evaluate meds and vitals to support severity of illness.
• Utilize monitoring tools to track Documentation Improvement Program metrics.
• Communicate findings to physicians and care team via queries.
• Coordinate with HIM, Utilization Review, Quality Management and physicians.
• Identify and implement process improvements for documentation accuracy.
• Distribute physician profiling reports generated by CDI software.
• Analyze reports to reflect severity of illness and therapy outcomes.
• Provide education to physicians and staff on documentation expectations.
• Protect patient confidentiality per HIPAA.
• Perform other duties as assigned.
• Identify need to clarify documentation using query tools.

Connaissances

Attention to detail

Critical thinking

Communication

Collaboration

Formation

RN License NM

Bachelor's Degree

CDIP/CDIS certification (optional)

Outils

MS-DRG software

Abstracting software

Coding software

Description du poste

UNMH Jobs in New Mexico seeks an experienced Registered Nurse with Clinical Documentation Improvement expertise to support the HIM Clinical Documentation department. You will review medical records to ensure accurate diagnoses and DRG assignments, communicating findings to physicians to improve documentation quality.

The role emphasizes concurrent review during hospitalization, collaboration with physicians and care teams, and ongoing education to enhance documentation standards.